An 87-year-old woman is evaluated for a 1-year history of bothersome insomnia. She reports taking up to 2 hours to fall asleep. She also feels that her sleep is less refreshing. She wakes up early in the morning without setting an alarm and sometimes takes 20-minute naps during the day. She has no other sleep-related symptoms, no current mood concerns, and no history of depression. She is otherwise healthy.
Which of the following is the most appropriate treatment?
A. Cognitive behavioral therapy for insomnia
MKSAP Answer and Critique
The correct answer is A. Cognitive behavioral therapy for insomnia. This content is available to MKSAP 19 subscribers as Question 12 in the General Internal Medicine 1 section. More information about MKSAP is available online.
Cognitive behavioral therapy for insomnia (CBT-I) (Option A) is the best treatment option for this patient with problematic sleep-onset insomnia, characterized by difficulty falling asleep. Decreased total sleep time, decreased rapid eye movement (REM) latency, reduced sleep efficiency, and earlier morning awakening are common physiologic changes to the sleep cycle in older adults. Initial evaluation of insomnia should consist of a thorough history and review of sleep hygiene. CBT-I is considered first-line treatment in all adults, including the geriatric population. Therapy can be individual, group, or internet based. There is a lack of evidence for or against any of these modes of CBT-I delivery as being the most effective. An abbreviated version of CBT-I, brief behavioral treatment for insomnia (BBT-I), focuses on the behavioral components of sleep restriction, stimulus control, and sleep hygiene only. BBT-I also has been shown to be effective in the treatment of chronic insomnia. In general, pharmacotherapy for sleep should be pursued only after shared decision making between the physician and patient.
Diphenhydramine (Option B) is an over-the-counter, first-generation antihistamine with sedative-hypnotic effects. It can cause anticholinergic side effects that are especially concerning in older patients. The 2019 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults from the American Geriatrics Society recommends avoidance of diphenhydramine in elderly patients such as this one, except in the acute treatment of severe allergic reaction.
Gabapentin (Option C) should generally be avoided in geriatric populations owing to increased risk for sedation. Use of gabapentinoids is sometimes acceptable in an older patient transitioning off opioid treatment for pain. Gabapentin is not approved for the treatment of insomnia.
Melatonin (Option D) is an over-the-counter sleep aid. It is often tried by patients and recommended by clinicians, but no conclusive evidence supports its effectiveness for sleep-onset insomnia. Evidence shows an approximately 7-minute decrease in sleep latency, an 8-minute increase in total sleep time, and a very small improvement in sleep quality.
Pramipexole (Option E) can be used for restless legs syndrome (RLS) when nonpharmacologic treatments and iron deficiency correction are ineffective. RLS is a movement disorder characterized by an uncomfortable urge to move the legs and is transiently relieved by movement. RLS is worse at rest and at night and may prevent sleep or interrupt sleep. This patient does not have symptoms consistent with RLS, and pramipexole should not be used for management of insomnia in patients who do not have RLS.
- Cognitive behavioral therapy for insomnia is first-line treatment in all adults with chronic insomnia, including the geriatric population.